Advertisement

A Standardized Multimodal Analgesia Protocol Reduces Perioperative Opioid Use in Minimally Invasive Colorectal Surgery

  • Angela Mujukian
  • Adam Truong
  • Hai Tran
  • Rita Shane
  • Phillip Fleshner
  • Karen ZaghiyanEmail author
Original Article

Abstract

Background

Multimodal analgesia protocols are becoming a common part of enhanced recovery pathways after colorectal surgery. However, few protocols include a robust intraoperative component in addition to pre-operative and post-operative analgesics.

Method

A prospective cohort study was performed in an urban teaching hospital in patients undergoing minimally invasive colorectal surgery before and after implementation of a multimodal analgesia protocol consisting of pre-operative (gabapentin, acetaminophen, celecoxib), intraoperative (lidocaine and magnesium infusions, ketorolac, transversus abdominis plane block), and post-operative (gabapentin, acetaminophen, celecoxib) opioid-sparing elements. The main outcome measure was use of morphine equivalents in the first 24-h post-operative period.

Results

The study cohort (n = 71) included 41 patients before and 30 patients after implementation of a multimodal analgesia protocol. Mean age of the entire study cohort was 47 ± 19.7 years and 46% were male. Patients undergoing surgery post-multimodal analgesia vs. pre-multimodal analgesia had significantly lower use of IV morphine equivalents in first 24-h post-operative period (5.8 ± 6.4 mg vs. 22.8 ± 21.3 mg; p = 0.005) and first 48-h post-operative period (7.6 ± 9.4 mg vs. 42 ± 52.9 mg; p = 0.0008). This reduction in IV morphine equivalent use post-multimodal analgesia was coupled with improved pain scores in the post-operative period. Post-operative hospital length of stay, post-operative ileus, and overall complications were not significantly different between groups.

Conclusions

Multimodal analgesia incorporating pre-operative, intraoperative, and post-operative opioid-sparing agents is an effective method for reducing perioperative opioid utilization and pain after minimally invasive colorectal surgery.

Keywords

Multimodal analgesia Enhanced recovery ERAS Transversus abdominis plane block Colorectal surgery 

Notes

Author Contributions

(per the International Committee of Medical Journal Editors (ICMJE) guidelines)

Angela Mujukian

• Substantial contributions to acquisition, analysis, or interpretation of data

• Original drafting; revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Adam Truong

• Substantial contributions to acquisition, analysis, or interpretation of data

• Revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Hai Tran

• Substantial contributions to conception and design of the work

• Revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Rita Shane

• Substantial contributions to conception and design of the work

• Revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Phillip Fleshner

• Substantial contributions to conception and design of the work

• Revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Karen Zaghiyan

• Substantial contributions to conception and design of the work; acquisition, analysis or interpretation of data

• Drafting and revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Compliance with Ethical Standards

The study was conducted in accordance with the ethical principles stated in the Declaration of Helsinki20 and local regulations. All research-related activities were approved by the Cedars-Sinai Medical Center Institutional Review Board (nos. 46571 and 54607). Written informed consent was obtained from all participants.

Conflict of Interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, Boutros M, McClane J, Feldman LS, Steele SR. (2017) Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum. 60:761–784.CrossRefGoogle Scholar
  2. 2.
    Wick EC, Grant MC, Wu CL. (2017) Postoperative multimodal analgesia pain management with an opioid analgesics and techniques: A review. JAMA Surg. 152:691–697.CrossRefGoogle Scholar
  3. 3.
    Helander EM, Webb MP, Bias M, Whang EE, Kaye AD, Urman RD. (2017) A comparison of multimodal analgesic approaches in institutional enhanced recovery after surgery protocols for colorectal surgery: Pharmacological agents. J Laparoendosc Adv Surg Tech A. 9:903–908.CrossRefGoogle Scholar
  4. 4.
    Joshi GP, Bonnet F, Kehlet H; PROSPECT collaboration. (2013) Evidence-based postoperative pain management after laparoscopic colorectal surgery. Colorectal Dis. 2:146–155.Google Scholar
  5. 5.
    Shaffer EE, Pham A, Woldman RL, Spiegelman A, Strassels SA Wan GJ. (2016) Estimating the effect of intravenous acetaminophen for postoperative pain management on length of stay in inpatient hospital costs. Advances in Therapy. 33:2211–2228.CrossRefGoogle Scholar
  6. 6.
    Hickamn SR, Mathieson KM, Bradford LM, Garman CD, Gregg RW, Lukens DW. (2018) Randomized trial of oral versus intravenous acetaminophen for postoperative pain control. Am J Health Syst Pharm. 75:367–375.CrossRefGoogle Scholar
  7. 7.
    Chen JY, Wu GJ, Mok MS, Chou YH, Sun WZ, Chen PL, Chan WS, Yien HW, Wen YR. (2005) Effect of adding ketorolac to intravenous morphine patient-controlled analgesia on bowel function in colorectal surgery patients—a prospective, randomized, double-blind study. Acta Anaesthesiol Scand. 49:546–551.CrossRefGoogle Scholar
  8. 8.
    Arumugam S, Lau CS, Chamberlain RS. (2016) Use of preoperative gabapentin significantly reduces postoperative opioid consumption: a meta-analysis. J Pain Res. 9:631–640.CrossRefGoogle Scholar
  9. 9.
    Yu N, Long X, Lujan-Hernandez JR, Succar J, Xin X, Wang X. (2014) Transversus abdominis-plane block versus local anesthetic wound infiltration in lower abdominal surgery: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol. 14:121.CrossRefGoogle Scholar
  10. 10.
    Oh TK, Lee SJ, Do SH, Song IA. (2018) Transversus abdominis plane block using a short-acting anesthetic for postoperative pain after laparoscopic colorectal surgery: A systematic review and meta-analysis. Surg Endosc. 32(2):545–552.CrossRefGoogle Scholar
  11. 11.
    Tikuisis R, Miliauskas P, Samalvicius NE, Zurauskas A, Samalavicius R, Zabulis V. (2014) Intravenous lidocaine for postoperative pain relief after hand-assisted laparoscopic colon surgery: A randomized, placebo-controlled trial. Tech Coloproctol. 18:373–380.CrossRefGoogle Scholar
  12. 12.
    Herroeder S, Pecher S, Schonherr ME, Kaulitz G, Hahnenkamp K, Friess H, Bottiger BW, Bauer H, Dijkgraaf MG, Durieux ME, Hollmann MW. (2007) Systemic lidocaine shortens length of hospital stay after colorectal surgery: A double-blinded, randomized, placebo-controlled trial. Ann Surg. 246:192–200.CrossRefGoogle Scholar
  13. 13.
    Shariat Mohararai R, Motalebi M, Najafi A, Zamani MM, Imani F, Etezadi F, Pourfakr P, Khajavi MR. (2013) Magnesium can decrease postoperative physiological ileus and postoperative pain in major non-laparoscopic gastrointestinal surgeries: A randomized controlled trial. Anesth Pain Med.4:e12750.Google Scholar
  14. 14.
    Abd-Elsalam KA, Fares KM, Mohamed MA, Mohamed MF, El-Rahman AMA, Tohamy MM. (2017) Efficacy of magnesium sulfate added to local anesthetic in a transversus abdominis plane block for analgesia following total abdominal hysterectomy: a randomized trial. Pain Physician. 20:641–647.Google Scholar
  15. 15.
    Atangana R, Ngowe Ngowe M, Binam F, Sossa MA. (2007) Morphine versus morphine-ketamine association in the management of postoperative pain in thoracic surgery. Acta Anaesthesiol Belg. 58:125–127.Google Scholar
  16. 16.
    Kim SH, Kim SI, Ok SY, Park SY, Kim MG, Lee SJ, Noh JI, Chun HR, Suh H. (2013) Opioid sparing effect of low dose ketamine in patients with intravenous patient-controleld analgesia using fentanyl after lumbar spinal fusion surgery. Korean J Anesthesiol. 64:524–528.CrossRefGoogle Scholar
  17. 17.
    Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, McMurry TL, Goudreau BJ, Umapathi BA, Kron IL, Sawyer RG, Hedrick TL. (2015) Standardization of care: impact of an enhanced recovery protocol on length of stay complications, and direct costs after colorectal surgery. J Am Coll Surg. 220(4):430–43.CrossRefGoogle Scholar
  18. 18.
    Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. (1973) Transection of the esophagus for bleeding esophageal varices. Br J Surg. 60(8):646–649.CrossRefGoogle Scholar
  19. 19.
    Zaghiyan K, Mendelson B, Eng M, Ovsepyan G, Mirocha J, Fleshner P. (2018). Randomized clinical trial comparing laparoscopic vs. ultrasound-guided transversus abdominis plane block in minimally invasive colorectal surgery. Dis Colon Rectum. Nov 28  https://doi.org/10.1097/DCR.0000000000001292.
  20. 20.
    World Medical Association. (Accessed 2018) https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/. -General Assembly, Helsinki, Finland, June 1964.
  21. 21.
    CMS.Gov. (Accessed 2016) https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Opioid-Morphine-EQ-Conversion-Factors-Aug-2017.pdf. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC) Compilation, Atlanta, GA.
  22. 22.
    Dindo D, Demartines N, Clavien PA. (2004) Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 240:205–213.CrossRefGoogle Scholar
  23. 23.
    Saleh F, Jackson TD, Ambrosini L, Gnanasegaramm JJ, Kwong J, Quereshy F, Okrainec A. (2014) Perioperative nonselective non-steroidal anti-inflammatory drugs are not associated with anastomotic leakage after colorectal surgery. J Gastrointest Surg. 8:1398–1404.CrossRefGoogle Scholar
  24. 24.
    Lohsiriwat V. (2016) Opioid-sparing effect of selective cyclooxygenase-2 inhibitors on surgical outcomes after open colorectal surgery within an enhanced recovery after surgery protocol. World J Gastrointest Oncol. 8:543–549.CrossRefGoogle Scholar
  25. 25.
    Hakkarainen TW, Steele SR, Bastaworous A, Dellinger EP, Farrokhi E, Farajah F, Florence M, Helton S, Horton S, Horton M, Pietro M, Varghese TK, Flum DR. (2015) Nonsteroidal anti-inflammatory drugs and the risk for anastomotic failure. JAMA Surg. 150:223–228.CrossRefGoogle Scholar
  26. 26.
    Modasi A, Pace D, Godwin M, Smith C, Curtis B. (2018) NSAID administration post colorectal surgery increases anastomotic leak rate: A systematic analysis and meta-analysis. Surg Endosc.  https://doi.org/10.1007/s00464-018-6355-1.
  27. 27.
    Ghuman A, Chan T, Karimuddin AA, Brown CJ, Raval MJ, Phang PT. (2015) Surgical site infection rates following implementation of a colorectal closure bundle in elective colorectal surgeries. Dis Colon Rectum. 58:1078–1082.CrossRefGoogle Scholar
  28. 28.
    Naito M, Sato T, Nakamura T, Yamanashi T, Miura H, Tsutsui A, Watanabe M. (2017) Pain management using acetaminophen through postoperative course of laparoscopic colorectal surgery: A case matched control study. Ann Med Surg (Lond). 17:38–42.CrossRefGoogle Scholar
  29. 29.
    Liska D, Bora Cengiz T, Novello M, Aiello A, Stocchi L, Hull TL, Steele Sr, Delaney CP, and Holubar SD. (2019) Do patients with inflammatory bowel disease benefit from an enhanced recovery pathway? Inflamm Bowel Dis. 2019 Aug 2.  https://doi.org/10.1093/ibd/izz172.
  30. 30.
    Aryaie AH, Lalezari S, Sergent WK, Yana Puckett, Christopher Juergens, Craig Ratermann, Cari Ogg.(2018)Decreased opioid consumption and enhance recovery with the addition of IV acetaminophen in colorectal patients: A prospective, multi-institutional , randomized, double-blinded, placebo-controlled (DOCIVA Study). Surg Endosc. 32:3432–3438.Google Scholar
  31. 31.
    Fleet JL, Dixon SN, Kuwornu PJ, Dev VK, Montero-Odasso M, Burneo J, Garg Ax. (2018) Gabapentin dose and the 30-day risk of altered mental status in older adults: A retrospective population-based study. Plos One. 13: e0193134.CrossRefGoogle Scholar
  32. 32.
    Maggiorgi L, Rullier E, Lefevre JH, Regimbeau JM, Berdah S, Karoui M Loriau J, Alves A, Vicaut E, Panis Y. (2017) Does a combination of laparoscopic approach and full fast track multimodal management decrease postoperative morbidity? A multicenter randomized controlled trial Ann Surg. 266:729–737.CrossRefGoogle Scholar
  33. 33.
    Allen CA, Ivester JR Jr. (2018) Low-dose ketamine for postoperative pain management. J Perianesth Nurs. 33:389–398.CrossRefGoogle Scholar
  34. 34.
    Murphy JD, Paskaradevan J, Eisler LL, Ouanes JP, Tomas VA, Freck EA, Wu CL. (2013) Analgesic efficacy of continuous intravenous magnesium infusion as an adjuvant to morphine for postoperative analgesia: A systematic review and meta-analysis. Middle East J Anaesthesiol. 22:11–20.Google Scholar
  35. 35.
    Albrecht E, Kirkham KR, Liu SS, Brull R. (2013) Peri-operative intravenous administration of magnesium sulphate and postoperative pain: a meta-analysis. Anaesthesia. 68:79–90.CrossRefGoogle Scholar
  36. 36.
    Pedrazzani C, Menestrina N, Moro M, Brazzo G, Mantovani G, Polati E, Guglielmi A. (2016) Local wound infiltration plus transversus abdominis plane (TAP) block versus local wound infiltration in laparoscopic colorectal surgery and ERAS program. Surg Endosc. 30:5117–5125.CrossRefGoogle Scholar
  37. 37.
    Kim AJ, Yong RJ, Urman RD. (2017) The role of transversus abdominis plane (TAP) blocks in enhanced recovery after surgery pathways for open and laparoscopic colorectal surgery. J Laparoendosc Adv Surg Tech A. 27:909–914.CrossRefGoogle Scholar
  38. 38.
    Halabi WJ, Kang CY, Nguyen VQ, Carmichael JC, Mills S, Stamos MJ, Pigazzi A. (2014) Epidural analgesia in laparoscopic colorectal surgery: A nationwide analysis of use and outcomes. JAMA Surg. 149: 130–136.CrossRefGoogle Scholar
  39. 39.
    Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, De Boer D, Urman RD, Change GJ, Fichera A, Kessler H et al. (2019) Guidelines for perioperative care in elective colorectal surgery: Enhanced recovery after surgery (ERAS) society recommendations: 2018. World Journal of Surgery. 43(3): 659–695.CrossRefGoogle Scholar
  40. 40.
    Alhashemi M, Fiore Jr. JF, Safa Nadia, Mahroos MA, Mata J, Pecorelli N, Baldini G, Dendukuri N, Stein BL, Liberman AS, Charlebois P, Carli F, and Feldman LS. Incidence and predictors of prolonged postoperative ileus after colorectal surgery in the context of an enhanced recovery pathway. (2019) Surgical Endoscopy. 22(7):2313–2322.Google Scholar
  41. 41.
    Brandstrup B, Svendsen PE, Rasmussen M, Belhage B, Rodt SA, Hansen B, Moller DR, Lundbech LB, Andersen N, Berg V, Thomassen N, Andersen ST, Simonsen L. (2012) Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth. 109: 191–199.CrossRefGoogle Scholar
  42. 42.
    Gomez-Izquierdo JC, Trainito A, Mirzakandov D, Stein BL, Liberman S, Charlebois P, Pecorelli N, Feldman L, Carli F, and Baldini G. (2017). Goal-directed fluid therapy does not reduce primary postoperative ileus after elective laparoscopic colorectal surgery: a randomized controlled trial. Anesthesiology. (127): 36-49.Google Scholar
  43. 43.
    Srinivasa S, Taylor MH, Singh PP, Yu TC, Soop M, and Hill AG. (2013). Randomized clinical trial of goal-directed fluid therapy within an enhanced recovery protocol for elective colectomy. Br J Surg. 100:66.CrossRefGoogle Scholar
  44. 44.
    Rollins KE, Lobo DN (2016). Intraoperative goal-directed fluid therapy in elective major abdominal surgery: a meta-analysis of randomized controlled trials. Ann Surg. (263)465-476. Google Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Angela Mujukian
    • 1
  • Adam Truong
    • 1
  • Hai Tran
    • 2
  • Rita Shane
    • 2
  • Phillip Fleshner
    • 1
  • Karen Zaghiyan
    • 1
    Email author
  1. 1.Division of Colon & Rectal SurgeryCedars Sinai Medical CenterLos AngelesUSA
  2. 2.Department of PharmacyCedars Sinai Medical CenterLos AngelesUSA

Personalised recommendations